Provider Demographics
NPI:1912037508
Name:WEINREB, JACK WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:WARREN
Last Name:WEINREB
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 MAIN ST
Mailing Address - Street 2:SUITE 153
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4343
Mailing Address - Country:US
Mailing Address - Phone:301-604-4423
Mailing Address - Fax:301-604-0020
Practice Address - Street 1:575 MAIN ST
Practice Address - Street 2:SUITE 153
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4343
Practice Address - Country:US
Practice Address - Phone:301-604-4423
Practice Address - Fax:301-604-0020
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD75081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice